Surgical instrument with double cartridge and anvil assemblies

ABSTRACT

An end effector for use with a surgical instrument having a first cartridge assembly configured to deploy a first set of fasteners and a second cartridge assembly disposed distally of the first cartridge assembly. The second cartridge assembly is configured to move between an open position and an approximated position relative to clamp tissue. A central rod extends between the first cartridge assembly and the second cartridge assembly.

This application claims priority from provisional application Ser. No.61/224,854, filed Jul. 11, 2009, the entire contents of which areincorporated herein by reference.

BACKGROUND

1. Technical Field

The present disclosure relates generally to surgical instruments andmethods for performing surgery. More specifically, the presentdisclosure relates to surgical instruments and methods for clamping,cutting, and/or joining tissue.

2. Background of Related Art

Certain surgical stapling instruments are used for applying rows ofstaples through compressed living tissue. These surgical staplinginstruments are employed, for example, for fastening tissue or organsprior to transaction or resection or during anastomoses. In some cases,these surgical stapling instruments are utilized for occluding organs inthoracic and abdominal procedures.

Typically, such surgical stapling instruments include an anvil assembly,a cartridge assembly for supporting an array of surgical staples, anapproximation mechanism for approximating the cartridge and anvilassemblies, and a firing mechanism for ejecting the surgical staplesfrom the cartridge assembly.

In use, a surgeon initially approximates the anvil and cartridgeassemblies. Next, the surgeon can fire the instrument to place staplesin tissue. Optionally, the surgeon may use the same instrument or aseparate device to cut the tissue adjacent or between the row(s) ofstaples.

SUMMARY

The present disclosure relates in one aspect to an end effector for usewith a surgical instrument. The end effector includes a first cartridgeassembly configured to deploy a first set of fasteners and a secondcartridge assembly disposed distally of the first cartridge assembly.The second cartridge assembly is configured to move between an openposition and an approximated position. A central rod extends between thefirst cartridge assembly and the second cartridge assembly.

The end effector preferably also includes a first anvil assemblydisposed distally of the first cartridge assembly and a second anvilassembly disposed distally of the first anvil assembly.

Preferably, each of the first anvil assembly and second anvil assemblyis mounted on the central rod for movement in response to movement ofthe central rod. The second cartridge assembly preferably includes asecond set of fasteners and a fastener pusher adapted to move between adistal position and a proximal position to eject the second set offasteners from the second cartridge.

In some embodiments, the second cartridge assembly includes a biasingmember, biasing a cartridge housing against the fastener pusher. Thefirst cartridge assembly can include a knife movable between a proximalposition and a distal position.

In some embodiments, the end effector is removably mountable to asurgical instrument.

In some embodiments, the first anvil assembly includes a plurality ofanvil pockets arranged in a substantially annular array and configuredto deform the first set of fasteners arranged in a substantially annulararray.

In another aspect, the present disclosure relates to a surgicalinstrument including a handle assembly and an elongated portionextending distally from the handle assembly. The elongated portion has aproximal portion and a distal portion. The surgical instrument furtherincludes an end effector disposed adjacent the distal portion of theelongated portion. The end effector includes a first cartridge assemblyconfigured to deploy a first set of fasteners, a first anvil assemblydisposed distally of the first cartridge assembly, a second anvilassembly disposed distally of the first anvil assembly, and a secondcartridge assembly disposed distally of the second anvil assembly. Thesecond cartridge assembly is configured to move between an open positionand an approximated position relative to the second anvil assembly. Acentral rod extends between the first cartridge assembly and the secondcartridge assembly.

In some embodiments, the second cartridge assembly is configured todeploy a second set of fasteners once the second cartridge assembly hasmoved to the approximated position and includes a fastener pusheradapted to move between a distal position and a proximal position toeject the second set of fasteners. Preferably, each of the first anvilassembly and the second anvil assembly is mounted on the central rod formovement in response to movement of the central rod.

The first cartridge assembly may further include a knife movable betweena proximal position and a distal position. The first and second sets offasteners can be arranged in a substantially annular array.

The present disclosure relates in another aspect to a method forperforming surgery. This method includes the steps of: (a) inserting anend effector inside a tubular organ, the end effector including a firstcartridge assembly housing a first set of fasteners, a first anvilassembly disposed distally of the first cartridge assembly, a secondanvil assembly disposed distally of the first anvil assembly, a secondcartridge assembly disposed distally of the second anvil assembly, andconfigured to move between an open position and an approximated positionrelative to the second anvil assembly, and a central rod extendingbetween the first cartridge assembly and the second cartridge assembly;(b) drawing a first tissue portion of the tubular organ toward thecentral rod and into a first area located between the second cartridgeassembly and the second anvil assembly; (c) drawing a second tissueportion of the tubular organ toward the central rod and into a secondarea located between the first anvil assembly and the second anvilassembly; (d) drawing a third tissue portion of the tubular organ towardthe central rod and into a third area located between the first anvilassembly and the first cartridge assembly; and (e) firing the endeffector to fasten together sections of the first tissue portion and tofasten sections of the third tissue portion.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a front perspective view of a surgical instrument according toan embodiment of the present disclosure;

FIG. 2 is a rear perspective view of the surgical instrument shown inFIG. 1;

FIG. 3 is a perspective view of a distal portion of the surgicalinstrument shown in FIGS. 1 and 2;

FIG. 4 is a longitudinal cross-sectional view of the surgical instrumentshown in FIGS. 1-3;

FIG. 5 is a longitudinal cross-sectional view of a handle assembly ofthe surgical instrument shown in FIG. 1, taken around section 5 of FIG.4;

FIG. 6 is a longitudinal cross-sectional view of the distal portion ofthe surgical instrument shown in FIG. 1, taken around section 6 of FIG.4;

FIG. 7 is a longitudinal view of the end effector of the surgicalinstrument shown in FIG. 1 positioned inside a body organ and showingsutures surrounding portions of the body organ;

FIG. 8 is a perspective view of the surgical instrument shown in FIG. 1in a first stage of operation of said surgical instrument;

FIG. 9 is a longitudinal cross-sectional view of a distal portion of thesurgical instrument shown in FIG. 1, depicting the stage of operation ofFIG. 8;

FIG. 10 is a longitudinal cross-sectional view of an anvil assembly anda cartridge assembly of the surgical instrument shown in FIG. 1 during afurther stage of operation;

FIG. 11 is a longitudinal cross-sectional view of the handle assembly ofthe surgical instrument of FIG. 1 in the approximated or fired position;

FIG. 12 is a longitudinal cross-sectional view of the end effectorcorresponding to the position of the handle assembly of FIG. 11;

FIG. 13 is a longitudinal view similar to FIG. 7 showing the endeffector inside a body organ after approximation and actuation; and

FIG. 14 is a longitudinal view of the body organ shown in FIG. 13 aftercutting and fastening of the body organ with the surgical instrument ofFIG. 1 and removal of the instrument.

DETAILED DESCRIPTION OF THE EMBODIMENTS

Embodiments of the presently disclosed surgical instrument are describedin detail with reference to the drawings, wherein like referencenumerals designate corresponding elements in each of the several views.In the description that follows, the term “proximal” refers to the endor portion of the surgical instrument closer to the user, whereas theterm “distal” refers to the end or portion of the surgical instrumentfurther away from the user.

FIGS. 1 and 2 illustrate an embodiment of the presently disclosedsurgical instrument 10. In the interest of brevity, the presentdisclosure focuses on end effectors for the disclosed surgicalinstrument. U.S. Pat. No. 7,303,106, the entire contents of which areincorporated herein by reference, describes in detail the structure andoperation of an embodiment of surgical instrument 10. In general,surgical instrument 10 includes a handle assembly 12, an elongatedcentral body portion 14 including a curved elongated outer tube 14 a,and an end effector or distal end (head) portion 16. Elongated centralbody portion 14 extends distally from handle assembly 12 and operativelycouples end effector 16 to handle assembly 12. In operation, endeffector 16 is approximated to clamp tissue upon actuation of anapproximation knob and fires fasteners and advances a cutting deviceupon actuation of handle assembly 12.

Handle assembly 12 includes a stationary handle 18, a pivotable firingtrigger 20, a rotatable approximation knob 22 and an indicator 24. Incertain embodiments, stationary handle 18 is made of a thermoplastic,such as polycarbonate. In other embodiments, stationary handle 18 isformed of an elastomeric material. Stationary handle 18 may neverthelessbe formed of any suitable material. In some embodiments, stationaryhandle 18 has a hollow body that houses internal components of handleassembly 12. U.S. Pat. No. 7,303,106, the entire contents of which havepreviously been incorporated by reference, describes in detail theinternal components of handle assembly 12.

Handle assembly 12 further includes a trigger lock 26 for preventing orat least minimizing the risk of inadvertently firing surgical instrument10 (e.g., prior to approximation of various portions of the endeffector). In the embodiment depicted in FIGS. 1 and 2, trigger lock 26is pivotally mounted to stationary handle 18. During use, trigger lock26 is configured to move relative to stationary handle 18 between alocked position and an unlocked position. In the locked position,trigger lock 26 engages firing trigger 20 and precludes, or at leasthinders, movement of firing trigger 20 with respect to stationary handle18. In the unlocked position, trigger 26 allows firing trigger 20 tomove or pivot relative to stationary handle 18. Stationary handle 18additionally includes an indicator 24 to indicate to a user whether endeffector 16 is approximated and is ready to be fired, for example.Indicator 24 may include a bulbous or convex shape extending outwardlyfrom a top surface of stationary handle 18.

As seen in FIG. 3, end effector 16 includes a first proximal cartridgeassembly 28 positioned at a distal end 30 of elongated central bodyportion 14, a second distal cartridge assembly 32 positioned at a moredistal location, a first anvil assembly 34, a second anvil assembly 36positioned distal of the first anvil assembly 34, and a central rod 38extending distally from first cartridge assembly 28 to second cartridgeassembly 32. First and second cartridge assemblies 28, 32 are bothconfigured to deploy or eject fasteners 78, 80 (FIG. 6), such asstaples. In certain embodiments, first and second cartridge assemblies28, 32 include one or more substantially annular rows of slots 44 eachadapted to retain one or more fasteners (FIG. 6) likewise arranged insubstantially annular rows. Although the drawings show second cartridgeassembly 32 (and first cartridge 28) with substantially annular rows ofslots 44, the slots of the cartridges may have other configurations.

With continued reference to FIG. 3, central rod 38 operativelyinterconnects first cartridge assembly 28, first anvil assembly 34,second anvil assembly 36, and second cartridge assembly 32. In someembodiments, central rod 38 protrudes about 2 to about 3 inches beyond adistal end 40 of first cartridge assembly 28. In the illustratedembodiments, central rod 38 includes one or more longitudinal keys 42along its length. Longitudinal keys 42 are configured to maintain theorientation of first and second anvil assemblies 34, 36 with respect tocenter rod 38 as first and second anvil assemblies 34, 36 each includekey slots (not shown) adapted to engage longitudinal keys 42 of centralrod 38. The engagement of longitudinal keys 42 of central rod 38 and keyslots (not shown) of first and second anvil assemblies 34, 36 assist inpreventing rotation of first and second anvil assemblies 34, 36 relativeto central rod 38 to maintain alignment of the anvil pockets of theanvil assemblies 34, 36 with the staples. When end effector 16 is fullyassembled, second cartridge assembly 32 is mounted on a distal end 46 ofcentral rod 38.

In addition, after end effector 16 has been fully assembled (either bythe user or alternatively in manufacture and shipped and packagedassembled), first anvil assembly 34 is positioned proximally relative tosecond anvil assembly 36. First anvil assembly 34 includes a tubularportion 50 and disk 52 adjacent a distal end 54 of tubular portion 50.Tubular portion 50 defines a longitudinal opening 64 extendingtherethrough. Longitudinal opening 64 is configured to accommodatecentral rod 38. Anvil assembly 34 is slidably positioned on central rod38. It is contemplated that tubular portion 50 may be made of a polymer,such as a plastic, or any other suitable material. Disk 52 may be formedof a metal, such as stainless steel, or any other suitable material.Disk 52 includes one or more anvil pockets or concavities 66 (FIG. 6)disposed on a proximal surface 56 thereof and thus face in a proximaldirection. Pockets 66 are adapted to deform fasteners 78 (FIG. 6)ejected in a distal direction from first cartridge assembly 28 intocontact with the pockets. In some embodiments, pockets 66 (FIG. 6) ofdisk 52 are arranged in substantially annular rows. Regardless of thespecific arrangement, pockets 66 (FIG. 6) of disk 52 are substantiallyaligned with slots 68 (FIG. 6) of first cartridge assembly 28. Thissubstantial alignment between pockets 66 (FIG. 6) of disk 52 and slots68 of first cartridge assembly 28 facilitates proper deformation offasteners 78 (FIG. 6) deployed from first cartridge assembly 28 duringthe firing process.

As seen in FIGS. 3 and 6, second anvil assembly 36 is located distallywith respect to first anvil assembly 34 when end effector 16 is fullyassembled. Second anvil assembly 36 includes a tubular portion 58 and adisk 60 adjacent a proximal end 62 of tubular portion 58. Tubularportion 58 defines a longitudinal opening 86 (FIG. 6) extendingtherethrough. Longitudinal opening 86 of tubular portion 58 isconfigured to receive central rod 38. Anvil assembly 36 is slidablypositioned on central rod 38. Moreover, tubular portion 58 may be madeof a polymer, such as plastic, or any other suitable material. Disk 60may be formed of a metal, such as stainless steel, or any other suitablematerial. Disk 60 includes one or more anvil pockets or concavities 82(FIG. 6) arranged on a distal surface (facing in a distal direction)adapted to deform fasteners 80 (FIG. 6) ejected from second cartridgeassembly 32 in a proximal direction into contact with the pockets 82during the firing process. Pockets 82 may be arranged in substantiallyannular rows on the distal surface 84 (FIG. 6) of disk 60. Regardless ofthe specific arrangement, pockets 82 (FIG. 6) of disk 60 aresubstantially aligned with slots 112 (FIG. 6) of second cartridgeassembly 32. This substantial alignment between pockets 82 (FIG. 6) ofdisk 60 and slots 112 of second cartridge assembly 32 facilitates properdeformation of fasteners 80 (FIG. 6). Disk 60 includes a cutting ring 61on a proximal side.

As noted above, anvil assemblies 34 and 36 are slidably mounted oncentral rod 38. A detent mechanism can be provided to retain the anvilassemblies 34, 36 in an initial position. As shown, detent 59 on aninner surface of tubular portion 58 of anvil assembly 36 engages agroove 39 formed in central rod 38. A detent 51 on an inner surface oftubular portion 50 of anvil assembly 34 engages a groove 37 formed incentral rod 38. In this manner, anvil assemblies 34 and 36 are held inposition on the central rod 38 until the instrument is approximated toclamp tissue as described below.

With reference to FIGS. 4 and 5, firing trigger 20 is operativelycoupled to a fastener pusher 72 positioned inside first cartridgeassembly 28. Surgical instrument 10 includes a firing link assembly 74operatively interconnecting firing trigger 20 and fastener pusher 72.Firing link assembly 74 extends from handle assembly 12 to firstcartridge assembly 28. In operation, actuation of firing trigger 20causes a distal translation of firing link assembly 74 which causes adistal translation of fastener pusher 72. Fastener pusher 72 includesone or more fingers 76 (FIG. 6) dimensioned to be received in slots 68of first cartridge assembly 28. When fastener pusher 72 moves distallyin response to an actuation of firing trigger 20 (due to distal movementof firing link assembly 74), fingers 76 move distally toward slots 68and urge fasteners 78 distally toward and into contact with first anvilassembly 34.

With continued reference to FIGS. 4-6, surgical instrument 10 furtherincludes an approximation link assembly 88 operatively couplingapproximation knob 22 to central rod 38. Rotation of knob 22 rotates aninternal screw which is operatively connected to link assembly 88 viapin 89 to thereby move link assembly 88 in a proximal or distaldirection, depending on the direction of rotation of knob 22.

As seen in FIG. 6, approximation link assembly 88 includes a rod 90protruding distally from first cartridge assembly 28, which canoptionally have a trocar tip as shown. Rod 90 can be pinned at aproximal region to approximation link assembly 88 via pins 91. Rod orshaft 90 is disposed in mechanical cooperation with central rod 38(e.g., in a friction-fit relationship). Central rod 38 defines alongitudinal opening 92 dimensioned to receive rod 90. Longitudinalopening 92 extends through a proximal portion 94 of central rod 38. Inoperation, a rotation of approximation knob 22 effects a translation ofapproximation link assembly 88. As approximation link assembly 88translates, connected rod 90 moves proximally or distally therewith.Since rod 90 is coupled to central rod 38, movement of rod 90 causescentral rod 38 to move as well. While central rod 38 moves, secondcartridge assembly correspondingly 32 moves in a distal or proximaldirection. A user therefore may approximate second cartridge assembly 32by rotating approximation knob 22 in a first direction (e.g.,clockwise). In response to rotation of knob 22 in a first direction,approximation link assembly 88 moves proximally and moves rod 90 in aproximal direction. As rod 90 moves proximally, central rod 38translates proximally and pulls second cartridge assembly 32 towardsecond anvil assembly 36 from an open position (e.g. FIG. 6) to anapproximated position (e.g. FIG. 9), as described in detail below.

As shown in FIG. 6, first cartridge assembly 28 further includes a knifeblade 96, or any suitable cutting device, movable between a retracted orproximal position and a deployed or distal position. Knife 96 isoperatively connected to fastener pusher 72 and may have an annularconfiguration or shape. In some embodiments, knife 96 is made of ametal, such as stainless steel. In the retracted position, knife 96 ispositioned within first cartridge assembly 28. In the deployed position,knife 96 is at least partially positioned outside of first cartridgeassembly 28 to sever tissue. While knife 96 moves between the retractedand deployed positions, at least a portion of knife 96 passes through anannular space 70 defined in first anvil assembly 34 and through abreakable annular portion 98, as discussed below.

With continued reference to FIG. 6, first anvil assembly 34 ispositioned on central rod 38 and includes annular space 70 defined intubular portion 50. Annular space 70 surrounds longitudinal opening 64and is dimensioned to receive knife 96. During use, annular space 70guides the translation of knife 96 through first anvil assembly 34.First anvil assembly 34 also includes a breakable or weakened annularportion 98 substantially axially aligned with annular space 70.Breakable annular portion 98 may be made of ceramic, plastic, or anyother suitable material and is positioned distally relative to annularspace 70. Breakable annular portion 98 is made of a material that can bebroken by knife 96 during the firing process. As knife 96 moves from theretracted position to the deployed position, knife 96 passes throughannular space 70 of first anvil assembly 34 and then breaks breakableannular portion 98 of first anvil assembly 34. After knife 96 breaksthrough breakable annular portion 98, knife 96 continues moving towardsecond anvil assembly 36. The outer portion of the anvil 34 broken offby the knife can pass through the body or otherwise captured andretrieved.

As depicted in FIG. 6, second anvil assembly 36 is positioned on centralrod 38 and includes tubular portion 58 having a proximal surface 100.Proximal surface 100 of tubular portion 58 serves as a knife cuttingtarget. As such, proximal surface 100 of tubular portion 58 receivesknife 96 and stops further distal translation of knife 96 during thefiring process. It is made of a suitable material which enables theknife to become embedded therein to stop distal advancement oralternately, as shown in FIG. 6, includes a cut ring 61 positioned inthe proximal surface into which the knife becomes embedded to limitmovement of the knife.

With continued reference to FIG. 6, second cartridge assembly 32includes a housing 102 for storing fasteners 80. Housing 102 defines aninner cavity 104 and a proximal aperture 106 dimensioned to receive atleast a portion of tubular portion 58 of second anvil assembly 36 andcentral rod 38. Second cartridge assembly 32 also includes one or moreslots 112 for retaining fasteners 80, a fastener pusher 108 disposed ininner cavity 104 and a biasing member 110 (such as a spring) operativelycoupled between housing 102 and center rod retainer ring 140. In someembodiments, slots 112 are arranged in substantially annular rows.Irrespective of their arrangement, slots 112 are substantially axiallyaligned with distally facing pockets 82 of second anvil assembly 36 tofacilitate proper deformation of fasteners 80 during the firing process.Fastener pusher 108 includes one or more fingers 114 adapted to urgefasteners 80 proximally toward second anvil assembly 36. Fingers 114 areconfigured to be received in slots 112 and extend in a proximaldirection. Biasing member 110, which can be in the form of a spring forexample, allows the fastener pusher 108 to move proximally independentlyfrom the cartridge housing 102 while second cartridge 32 is abuttingcompressed tissue.

As depicted in FIG. 6, fastener pusher 108 includes a tubular portion119 defining a longitudinal lumen 118. Longitudinal lumen 118 isconfigured to receive a distal end 46 (FIG. 3) of central rod 38 andconfigured for permanent attachment to center rod 38.

A retainer ring 140 rests in groove 37 of center rod 38. Cartridgehousing 102 of second cartridge 32 is biased by member 110 against adistal surface of fastener pusher 108. Biasing member 110 securesinitial positioning relation of fasteners 80 and fastener pusher 108 tosecond cartridge 32 prior to clamping. Cartridge housing 102 includeshousing cap 107 to prevent exposure of biasing member 110 and retainerring 140 to body fluids and tissue.

FIGS. 7-14 illustrate the operation of surgical instrument 10. Asdiscussed above, a clinician may use surgical instrument 10 to performnumerous surgical procedures. For example, surgical instrument 10 can beutilized to conduct a lower anterior resection. In any case, theclinician may employ surgical instrument 10 to clamp, cut, and/or jointissue. Before initiating operation of surgical instrument 10, if theinstrument is shipped with the anvil and cartridge assemblies unattachedto the instrument, the clinician assembles end effector 16 by attachingcenter rod 38 to rod 90 as described above. In alternate embodiments,the instrument can be packaged fully assembled with the rod 90 attachedto the center rod 38. In other embodiments, the center rod 38 withattached second cartridge 32, the first anvil assembly 34, and thesecond anvil assembly 36 are provided as separate components forattachment to the instrument. In such embodiments, the clinician wouldfirst slide first and second anvil assemblies 34, 36 onto central rod38. (In the embodiment with detents, the clinician would slide the anvilassemblies onto the central rod 38 until the detent mechanisms discussedabove engage and provide a tactile feel to the clinician that they arein place).

Once end effector 16 is assembled, the clinician can clamp tissue, cut,and/or join tissue. In one exemplary embodiment, end effector 16 isinserted inside a tubular organ “O”, such as a bowel, through thepatient's anus until end effector 16 reaches an area adjacent to thetumor or desired surgical site.

As seen in FIGS. 7 and 9, to clamp tissue, the clinician first placesend effector 16 adjacent to tissue such that a first tissue portion T1is positioned between first cartridge assembly 28 and first anvilassembly 34, a second tissue portion T2 is positioned between firstanvil assembly 34 and second anvil assembly 36, and a third tissueportion T3 is positioned between second anvil assembly 36 and secondcartridge assembly 32. Subsequently, the clinician wraps three pursestring sutures S1, S2, S3 around tubular organ “O” and tightens suturesS1, S2, S3 to draw portions of tubular organ “O” closer to central rod38. Specifically, one suture S1 is wrapped and tightened around tissueportion T1, which is located between the first cartridge assembly 28 andfirst anvil assembly 34, another suture S2 is wrapped and tightenedaround tissue portion T2, which is located between first anvil assembly34 and second anvil assembly 36, and yet a further suture S3 is wrappedand tightened around tissue portion T3, which is located between secondanvil assembly 36 and second cartridge assembly 32. As shown, tissueportion T1 is tightened against tubular portion 50 of first anvilassembly 34, tissue portion T2 is tightened against central rod 38 andthird tissue portion T3 is tightened against tubular portion 58 ofsecond anvil assembly 36.

Thereafter, the clinician rotates approximation knob 22 relative tostationary handle 18 in the direction indicated by arrow “A” (see FIG.8), for example, to move end effector 16 from an open position (FIG. 6)to an approximated position (FIGS. 8 and 9). That is, in response tothis rotation, central rod 38 moves proximally (due to its operativeconnection to rod 90 and approximation link assembly 88) and thereforeurges second cartridge assembly 32, first anvil assembly 34, and secondanvil 36 assembly in a proximal direction as indicated by arrow “B” toclamp the tissue portions T1, T2, T3 (See FIGS. 8 and 9). Note that asthe central rod is approximated, the anvil assemblies can slide alongcentral rod to clamp tissue. As central rod 38 moves proximally in thedirection indicated by arrows “B,” so does attached cartridge housing102 and after sufficient movement eventually starts to compress tissuebetween second cartridge 32 and second anvil 36. At some point,resistance of clamped tissue becomes so great that it stops movement ofcartridge housing 102 with respect to second anvil 36 and startsmovement with respect to center rod 38. Relative motion between centerrod 38 and cartridge housing 102 is possible due to elastic propertiesof biasing member 110.

After clamping and compression of tissue between second cartridge 32 andsecond anvil 36, center rod 38 with attached fastener pusher 108approximates further in the direction indicated by arrows “D” (FIG. 10)driving fingers 114 proximally into slots 112. Fingers 114 then pushfasteners 80 out of second cartridge assembly 32 (into contact withpockets 82) to fasten the third tissue portion T3 (FIG. 10) clampedbetween second cartridge assembly 32 and second anvil assembly 36. Thus,as can be appreciated, the fasteners 80 are fired after the anvilassembly 36 and second cartridge assembly 32 are approximated. By firingthe fasteners, a peripheral portion of the organ is clamped as can beseen in FIG. 10 which reduces leakage by limiting flow.

To eject fasteners 78 housed in first cartridge assembly 32, theclinician actuates handle assembly 12 by moving firing trigger 20 towardstationary handle 18 in the direction indicated by arrow “E” (FIG. 11).Upon actuation of handle assembly 12, firing link assembly 74 translatesdistally in the direction indicated by arrow “F” (FIG. 11). In responseto the distal translation of firing link assembly 74, fastener pusher 72moves distally in the direction indicated by arrow “G,” (FIG. 12)driving fingers 76 into slots 68. Consequently, fingers 76 pushfasteners 78 out of first cartridge assembly 28 to fasten the firsttissue portion T1 (FIG. 12) located between first cartridge assembly 28and first anvil assembly 34. The distal movement of fastener pusher 72also causes knife 96 to move distally toward first anvil assembly 34. Asa consequence, knife 96 travels through annular space 70 of first anvilassembly 34 and then breaks through breakable annular portion 98 toreach proximal surface 100 of tubular portion 58 (see FIG. 12) where itbecomes embedded in cut ring 61. During this distal translation, knife96 cuts the second tissue portion T2 located between first anvilassembly 34 and second anvil assembly 36. The clinician then moves endeffector 16 back toward the open position by rotating knob 22 in theopposite direction, thereby moving approximation link assembly 88 in adistal direction to move the first and second anvil assemblies 34, 36and the second cartridge assembly 32 distally. The surgeon then removesthe surgical instrument 10 from tubular organ “O” (FIG. 14).

Thereafter, a circular anastomosis instrument can be inserted throughthe lower tissue portion and into the tubular organ O. The instrument isclamped to approximate the two portions (since a tissue portion inbetween has been removed) and then staples are fired to join theportions.

Thus, as can be appreciated, one use of the instrument is in a loweranterior resection procedure. Clamping of the tissue organ O above theintended resection area enables wash out (cleaning out) of the areabelow the clamping, with stapling occurring below the clamping. This isachieved with access through the anus of the patient.

While the above description contains many specifics, these specificsshould not be construed as limitations on the scope of the presentdisclosure, but merely as illustrations of various embodiments thereof.Therefore, the above description should not be construed as limiting,but merely as exemplifications of various embodiments. Those skilled inthe art will envision other modifications within the scope and spirit ofthe disclosure.

1. A surgical instrument for joining tissue, comprising: a handleassembly; an elongated portion extending distally from the handleassembly and defining a longitudinal axis, the elongated portion havinga proximal portion and a distal portion; an end effector disposedadjacent the distal portion of the elongated portion, the end effectorincluding: a first cartridge assembly configured to deploy a first setof fasteners, the first cartridge assembly being positionedsubstantially along the longitudinal axis; a first anvil assemblydisposed distally of the first cartridge assembly, the first anvilassembly being positioned substantially along the longitudinal axis; asecond anvil assembly disposed distally of the first anvil assembly, thesecond anvil assembly being positioned substantially along thelongitudinal axis; a second cartridge assembly disposed distally of thesecond anvil assembly, the second cartridge assembly being positionedsubstantially along the longitudinal axis, wherein the second cartridgeassembly is configured to move between an open position and anapproximated position relative to the second anvil assembly; and acentral rod extending between the first cartridge assembly and thesecond cartridge assembly the central rod movable substantially alongthe longitudinal axis to move the second cartridge assembly between theopen and approximated positions.
 2. The surgical instrument of claim 1,wherein the second cartridge assembly is configured to deploy a secondset of fasteners once the second cartridge assembly has moved to theapproximated position, the second cartridge assembly including afastener pusher adapted to move between a distal position and a proximalposition to eject the second set of fasteners.
 3. The surgicalinstrument of claim 1, wherein each of the first anvil assembly and thesecond anvil assembly is mounted on the central rod for movement inresponse to movement of the central rod.
 4. The surgical instrument ofclaim 1, wherein the first cartridge assembly further comprises a knifemovable between a proximal position and a distal position, wherein thefirst anvil assembly includes a weakened portion that is configured tobreak when the knife moves therethrough.
 5. The surgical instrument ofclaim 2, wherein the first and second sets of fasteners are arranged ina substantially annular array.
 6. The surgical instrument of claim 1,wherein the first and second sets of fasteners are arranged in asubstantially annular array.